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Physician documentation

Rieke Schnakenberg, Lukas Radbruch, Christine Kersting, Friederike Frank, Stefan Wilm, Denise Becka, Klaus Weckbecker, Markus Bleckwenn, Johannes M Just, Michael Pentzek, Birgitta Weltermann
BACKGROUND: Although general practitioners (GPs) are among the preferred contact persons for discussing end-of-life issues including advance directives (ADs), there is little data on how GPs manage such consultations. OBJECTIVES: This postal survey asked German GPs about their counselling for end-of-life decisions. METHODS: In 2015, a two-sided questionnaire was mailed to 959 GPs. GPs were asked for details of their consultations on ADs: frequency, duration, template use, and whether they have own ADs...
December 2018: European Journal of General Practice
Shuangshuang Lu, Jiayi Wu, Yan Fang, Wei Wang, Yu Zong, Xiaosong Chen, Ou Huang, Jian-Rong He, Weiguo Chen, Yafen Li, Kunwei Shen, Li Zhu
Introduction: Approximately 5% of primary breast cancer patients present de novo stage IV breast cancer, for whom systematic therapy is the mainstream treatment. The role of surgical excision of the primary tumor has been controversial due to inconsistent results of relevant studies. Recently, with the reports of some relevant preclinical data, retrospective studies and randomized clinical trials, we've got more evidence to reexamine the issue. Based on those above, a literature review and meta-analysis was performed to determine whether surgery of the primary tumor could improve overall survival in the setting of stage IV breast cancer...
February 20, 2018: Oncotarget
Kurt P Spindler, Laura J Huston, Kevin M Chagin, Michael W Kattan, Emily K Reinke, Annunziato Amendola, Jack T Andrish, Robert H Brophy, Charles L Cox, Warren R Dunn, David C Flanigan, Morgan H Jones, Christopher C Kaeding, Robert A Magnussen, Robert G Marx, Matthew J Matava, Eric C McCarty, Richard D Parker, Angela D Pedroza, Armando F Vidal, Michelle L Wolcott, Brian R Wolf, Rick W Wright
BACKGROUND: The long-term prognosis and risk factors for quality of life and disability after anterior cruciate ligament (ACL) reconstruction remain unknown. Hypothesis/Purpose: Our objective was to identify patient-reported outcomes and patient-specific risk factors from a large prospective cohort at a minimum 10-year follow-up after ACL reconstruction. We hypothesized that meniscus and articular cartilage injuries, revision ACL reconstruction, subsequent knee surgery, and certain demographic characteristics would be significant risk factors for inferior outcomes at 10 years...
March 2018: American Journal of Sports Medicine
Rhondene M Miller, Ronald S Kaiser
PURPOSE OF REVIEW: The complicated nature of chronic pain involves an interplay between psychological and physical factors, often resulting in increased emotional distress and reduced quality of life. This review is designed to help the medical practitioner who is working with chronic pain patients to be aware of psychological assessment techniques that can add to comprehensive patient understanding and more effectively guide treatment. Enhanced ability to assess and understand the emotional life of the chronic pain patient provides a basis for intervening and treating more successfully...
March 14, 2018: Current Pain and Headache Reports
Eiman Zargaran, Richard Spence, Lauren Adolph, Andrew Nicol, Nadine Schuurman, Pradeep Navsaria, Damon Ramsey, S Morad Hameed
Importance: Collection and analysis of up-to-date and accurate injury surveillance data are a key step in the maturation of trauma systems. Trauma registries have proven to be difficult to establish in low- and middle-income countries owing to the burden of trauma volume, cost, and complexity. Objective: To determine whether an electronic trauma health record (eTHR) used by physicians can serve as simultaneous clinical documentation and data acquisition tools. Design, Setting, and Participants: This 2-part quality improvement study included (1) preimplementation and postimplementation eTHR study with assessments of satisfaction by 41 trauma physicians, time to completion, and quality of data collected comparing paper and electronic charting; and (2) prospective ecologic study describing the burden of trauma seen at a Level I trauma center, using real-time data collected by the eTHR on consecutive patients during a 12-month study period...
March 14, 2018: JAMA Surgery
Martin Dlouhý
The existence of geographic differences in health resources, health expenditures, the utilization of health services, and health outcomes have been documented by a lot of studies from various countries of the world. In a publicly financed health system, equal access is one of the main objectives of the national health policy. That is why inequalities in the geographic allocation of health resources are an important health policy issue. Measures of inequality express the complexity of variation in the observed variable by a single number, and there is a variety of inequality measures available...
2018: Frontiers in Public Health
Yolanda K Mueller, Stefanie Monod, Isabella Locatelli, Christophe Büla, Jacques Cornuz, Nicolas Senn
BACKGROUND: Geriatric syndromes are rarely detected in family medicine. Within the AGE program (active geriatric evaluation), a brief assessment tool (BAT) designed for family physicians (FP) was developed and its diagnostic performance estimated by comparison to a comprehensive geriatric assessment. METHODS: This prospective diagnostic study was conducted in four primary care sites in Switzerland. Participants were aged at least 70 years and attending a routine appointment with their physician, without previous documented geriatric assessment...
March 13, 2018: BMC Geriatrics
Malhar P Patel, Priscille Schettini, Colin P O'Leary, Hayden B Bosworth, John B Anderson, Kevin P Shah
PURPOSE: Ideally, a referral from a primary care physician (PCP) to a specialist results in a completed specialty appointment with results available to the PCP. This is defined as "closing the referral loop." As health systems grow more complex, regulatory bodies increase vigilance, and reimbursement shifts towards value, closing the referral loop becomes a patient safety, regulatory, and financial imperative. OBJECTIVE/DESIGN: To assess the ability of a large health system to close the referral loop, we used electronic medical record (EMR)-generated data to analyze referrals from a large primary care network to 20 high-volume specialties between July 1, 2015 and June 30, 2016...
March 12, 2018: Journal of General Internal Medicine
Anuj K Dalal, Adam Schaffer, Esteban F Gershanik, Ranganath Papanna, Katyuska Eibensteiner, Nyryan V Nolido, Cathy S Yoon, Deborah Williams, Stuart R Lipsitz, Christopher L Roy, Jeffrey L Schnipper
BACKGROUND: Follow-up of tests pending at discharge (TPADs) is poor. We previously demonstrated a twofold increase in awareness of any TPAD by attendings and primary care physicians (PCPs) using an automated email intervention OBJECTIVE: To determine whether automated notification improves documented follow-up for actionable TPADs DESIGN: Cluster-randomized controlled trial SUBJECTS: Attendings and PCPs caring for adult patients discharged from general medicine and cardiology services with at least one actionable TPAD between June 2011 and May 2012 INTERVENTION: An automated system that notifies discharging attendings and network PCPs of finalized TPADs by email MAIN MEASURES: The primary outcome was the proportion of actionable TPADs with documented action determined by independent physician review of the electronic health record (EHR)...
March 12, 2018: Journal of General Internal Medicine
Philippe Martin, Cara Tannenbaum
Context: Interprofessional communication is an effective mechanism for reducing inappropriate prescriptions among older adults. Physicians' views about which elements are essential for pharmacists to include in an evidence-based pharmaceutical opinion for deprescribing remain unknown. Objective: To develop a prototype for an evidence-based pharmaceutical opinion that promotes physician-pharmacist communication around deprescribing. Methods: A standardized template for an evidence-based pharmaceutical opinion was developed with input from a convenience sample of 32 primary care physicians and 61 primary care pharmacists, recruited from conferences and community settings in Montreal, Canada...
March 2018: Canadian Pharmacists Journal: CPJ, Revue des Pharmaciens du Canada: RPC
(no author information available yet)
Cardiovascular prevention represents a cornerstone of modern strategies to reduce the burden of cardiovascular disease. It is of key importance to prevent cardiovascular diseases and associated events, not only to reduce morbidity and mortality, but also to increase the years of wellness in the aging population and to make the growing socio-economic burden imposed by cardiovascular events more sustainable.The current approach to prevention is based on an integrated use of effective lifestyle measures and, whenever appropriate, of antihypertensive and antidiabetic drugs, lipid-lowering agents and antiplatelet drugs...
February 2018: Giornale Italiano di Cardiologia
Susanne Blödt, Maleen Kaiser, Yvonne Adam, Sandra Adami, Martin Schultze, Jacqueline Müller-Nordhorn, Christine Holmberg
OBJECTIVE: To analyse the role and meaning of health information in individuals' experiences with either breast, colorectal or prostate cancer in order to better understand unmet information needs of people with a cancer diagnosis. DESIGN: This is a secondary analysis of data from a qualitative interview study including narrative interviews and maximum variation sampling. A thematic analysis was conducted, followed by an in-depth analysis based on the principles of grounded theory...
March 12, 2018: BMJ Open
Ryan Howard, Rishindra M Reddy
OBJECTIVE: Accurate medical documentation is a core competency in medical education and is critical to successful surgical practice. The following study aims to assess the coding accuracy of medical student documentation. DESIGN: Retrospective chart review identified patient encounters in a surgery clinic that contained documentation by both a faculty member and a third-year medical student. Records were de-identified and assigned a level of service (LOS) and diagnostic code by trained, expert coders...
March 9, 2018: Journal of Surgical Education
Leah L Zullig, Katherine Ramos, Callie Berkowitz, Julie J Miller, Rowena J Dolor, Bridget F Koontz, S Yousuf Zafar, D Hutch Allen, Jennifer A Tenhover, Hayden B Bosworth
Cancer survivorship care plans (SCPs) are endorsed to support quality care for cancer survivors, but uptake is slow. We assessed knowledge, needs, and preferences for SCP content and delivery from a wide variety of stakeholders. We focused SCP content for head and neck cancer as it is a disease prone to long-term side effects requiring management from multiple providers. We conducted telephone-based, qualitative interviews. We purposively sampled head and neck cancer survivors (n = 4), primary care physicians in the community (n = 5), and providers affiliated with a large academic medical center (n = 5) who treat head and neck cancer, cancer specialists (n = 6), and nurse practitioners/supportive care staff (n = 5)...
March 10, 2018: Journal of Cancer Education: the Official Journal of the American Association for Cancer Education
Ryan Tewell, Lisa Edgerton, Elizabeth Kyle
PURPOSE: A program at a family medicine clinic to provide naloxone prescriptions in conjunction with education on naloxone use and opioid hazards to patients at risk for opioid overdose is described. SUMMARY: Consistent with a 2016 Centers for Disease Control and Prevention (CDC) guideline on opioid prescribing for chronic pain, a family medicine clinic implemented updated controlled substance agreements and medical record templates for documentation of pain management visits and established a pharmacist-led naloxone clinic...
March 15, 2018: American Journal of Health-system Pharmacy: AJHP
Ray Coniglio, Constance McGraw, Mike Archuleta, Heather Bentler, Leigh Keiter, Julie Ramstetter, Elizabeth Reis, Cristi Romans, Rachael Schell, Kelli Ross, Rachel Smith, Jodi Townsend, Alessandro Orlando, Charles W Mains
Colorado requires Level III and IV trauma centers to conduct a formal performance improvement program (PI), but provides limited support for program development. Trauma program managers and coordinators in rural facilities rarely have experience in the development or management of a PI program. As a result, rural trauma centers often face challenges in evaluating trauma outcomes adequately. Through a multidisciplinary outreach program, our Trauma System worked with a group of rural trauma centers to identify and define seven specific PI filters based on key program elements of rural trauma centers...
March 2018: Journal of Trauma Nursing: the Official Journal of the Society of Trauma Nurses
Thomas R Radomski, Felicia R Bixler, Susan L Zickmund, KatieLynn M Roman, Carolyn T Thorpe, Jennifer A Hale, Florentina E Sileanu, Leslie R M Hausmann, Joshua M Thorpe, Katie J Suda, Kevin T Stroupe, Adam J Gordon, Chester B Good, Michael J Fine, Walid F Gellad
BACKGROUND: The Department of Veterans Affairs (VA) has implemented robust strategies to monitor prescription opioid dispensing, but these strategies have not accounted for opioids prescribed by non-VA providers. State-based prescription drug monitoring programs (PDMPs) are a potential tool to identify VA patients' receipt of opioids from non-VA prescribers, and recent legislation requires their use within VA. OBJECTIVE: To evaluate VA physicians' perspectives and experiences regarding use of PDMPs to monitor Veterans' receipt of opioids from non-VA prescribers...
March 8, 2018: Journal of General Internal Medicine
Andreas G Schreyer, Britta Rosenberg, René T Steinhäuser
BACKGROUND:  Because of an increasing number of boards and conferences, the number of second opinion readings of externally acquired image data is growing dramatically. In this review article we intend to give medical and legal recommendations for the documentation and interpretation of externally acquired radiological data for second opinions and board presentations based on German jurisdiction. METHOD:  Using the FAQ format as a dialog between radiologists and medical legal experts, we answer the most crucial questions regarding correct documentation and interpretation for externally acquired radiological image data based on an up-to-date literature search...
March 7, 2018: RöFo: Fortschritte Auf Dem Gebiete der Röntgenstrahlen und der Nuklearmedizin
Mansour Naseriasl, Ali Janati, Abolgasem Amini, Davoud Adham
Because of insufficient communication between primary health care providers and specialists, which leads to inefficiencies and ineffectiveness in rural population health outcomes, to implement a well-functioning referral system is one of the most important tasks for some countries. Using purposive and snowballing sampling methods, we included health experts, policy-makers, family physicians, clinical specialists, and experts from health insurance organizations in this study according to pre-determined criteria...
March 5, 2018: Cadernos de Saúde Pública
Shahzad Ahmed, Christopher V Almario, William D Chey, Lori A Robbins, Bianca Chang, Joseph Ahn, Jeffrey Ko, Phillip Gu, Alvin Siu, Brennan M R Spiegel
OBJECTIVE: Little is known about the agreement between referring providers' reason for specialty evaluation and patients' understanding of why they are referred for consultation. Here, we compared the reason for consult (RFC) documented by referring providers during usual care vs. the perceived RFC independently reported by patients through an e-portal just prior to the specialist visit. METHODS: We performed an observational study among patients referred for gastrointestinal (GI) evaluation...
March 6, 2018: Informatics for Health & Social Care
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